Archived: Cadogan Court

Cadogan Court is registered to provide accommodation with nursing and personal care, for up to 70 people. The service is offered to older people, including those who may have support needs due to dementia. At the time of the inspection there were 62 people living at Cadogan Court. The provider is The Royal Masonic Benevolent Institution (RMBI), who provides care for older Freemasons and their families as well as some people in the community.

There was a newly registered manager in post. Like registered providers, registered managers are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home had been without a registered manager for five months, and health professionals told us it had been “without leadership for a long time”. This had impacted significantly on the quality of the service. A comprehensive service improvement plan was in place, and actions were being taken to address the failings identified. However, at the time of the inspection it was it was not possible to determine how effective these actions would be in keeping people safe and improving the quality of service provision.

The needs of people in the home varied. Some people had complex nursing needs and remained in bed; some had mental health needs and needed constant support and supervision while others were relatively independent and needed little support. A lot of staff had left, and the home had relied on agency staff to maintain staffing levels for over a year. People, relatives and staff expressed concern that agency staff did not always have the knowledge and skills to meet people’s needs safely. In addition, agency staff required additional support, which doubled the workload of the permanent staff. This situation had the greatest impact on people with higher support needs.

People’s legal rights were not always fully protected because some people had restrictions in place, such as bed rails or pressure mats, but there had been no consideration of whether these restrictions were in their best interests. In addition some ‘blanket’ best interest decisions had been made relating to ‘all aspects of care’, rather than a specific decision, which indicates the MCA was not well understood. Staff training needed to improve to ensure people received a service from staff who were appropriately trained.

People had access to healthcare services for on-going healthcare support, however health and social care professionals did not always know if their recommendations had been shared with staff or acted on due to a breakdown in communication. This meant there was a risk people’s healthcare needs would not be met.

Although some care plans were comprehensive and detailed, this was not consistent, which meant they did not always provide the guidance staff needed to meet people’s care needs safely and effectively. This lack of information increased the risks for people, particularly if staff were less familiar with the person, for example when a person without the capacity to understand the risks, refused to be supported by care staff.

Prior to the inspection there had been a significant number of medication errors at the home and people had been put at risk. The registered manager was acting decisively to manage this risk, and the service improvement plan aimed to ensure people’s medicines were managed so they received them safely.

The newly registered manager provided strong leadership. A recruitment drive was underway, which would decrease the need to use agency staff. They had introduced clear boundaries and discipline for staff, and were developing clear lines of accountability and responsibility. They were proactive in building a culture of transparency and openness at the home. People, relatives, staff and external professionals had confidence in their ability to ‘turn things around’. A member of staff told us, “[Registered manager] is bringing structure and clarity. They have reinforced that we are a good team. We all need to work as a team over the next six months. They are approachable. They listen”. The registered manager had taken action to improve staff support and training, and was using increased monitoring and audit processes to identify what was working well and where improvements needed to be made. They were acting to improve information sharing across the staff team and with agency staff, by introducing ‘wardrobe’ care plans which summarised people’s support needs, and ensuring recording, handovers and staff meetings were more responsive and effective. They were also proactive in improving communication with external agencies, building positive working relationships with local GPs, pharmacists, health care specialists, volunteers and community for the benefit of the people living at Cadogan Court.

At the time of the inspection the ‘Dementia House’, was near completion. This was a separate wing of the home catering for people living with dementia who had more complex support needs.

Staff promoted people’s independence and treated them with dignity and respect. One person said,” I'm quite contented here, very well looked after". A relative commented, “The permanent staff are ‘over’ and ‘above’. They are amazing, wonderful and compassionate”. People were supported to make choices about their day to day lives, such as what to wear and how they wanted to spend their time.

People were supported to maintain ongoing relationships with their families and friends. Relatives told us they were kept informed about the well-being of their family member, and felt able to visit them at any time.

The registered manager encouraged people and their relatives to voice any concerns, either using the provider’s complaints process or at one of the regular residents/relatives meetings. Relatives told us about concerns they had raised, and how the registered manager had resolved them. Comments included; “I would raise concerns. They are very approachable” and, “The manager wants to know so they can deal with things”.

People’s individual nutritional requirements were assessed and they received a diet appropriate to their needs and wishes. The catering staff worked hard to make mealtimes an enjoyable and sociable experience for people. The catering manager told us, “There are not many things that people look forward to more than their food. It’s a social event, and we need to make that experience as pleasant as possible”.

People could choose to participate in organised activities and were supported to organise their own activities if they wanted to. There was a wide range of activities, organised by activity co-ordinators and external volunteers and organisations. Activities staff worked to involve everybody according to their individual needs and ability to participate.

There were systems in place to make sure the premises and equipment were safe for people.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Before our inspection we reviewed all the information we held about the home. We examined previous inspection reports and notifications received by the Care Quality Commission.

On the day of our visit we were told that there were 53 people living at Cadogan Court. We spoke to approximately one third of people living at the home, three people's families, spent time observing the care people were receiving, spoke to ten members of staff, which included the registered manager, looked at four people's care files in detail, and quality assurance systems.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The service was safe because people's health and care needs were understood by a trained and supported staff. Risks to people's health and welfare were understood and managed in line with their agreement. For example, a pressure mat to prevent falls.

There was monitoring of events and incidents and measures were put in place to minimise a repeat of any issues. This included, changes to health care needs and some medication incidents. People's medicines were being managed on their behalf in a competent way.

The arrangements for staffing were generally safe and under review but people felt more staff were needed and we saw that safety might be compromised because changes to people's needs did not always prompt a timely change in their care plan.

Care plans included considerations of the Mental Capacity Act (2005) and staff demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and how they applied to their practice. We found the location to be meeting the requirements of the Mental Capacity Act (2005). People's human rights were therefore properly recognised, respected and promoted.

Is the service effective?

The service was effective because people's health and well-being was promoted. Their quality of life was optimised. One person's family told us, 'The care is very good and X is known by staff because there is continuity of care and their understanding of dementia is good'. People did not appear rushed and the home was relaxed and welcoming. There was a wide variety of activities available to people which included outings, pottery and music.

Care plans were written with detailed instructions so staff knew how to provide the individual care people wanted and needed. We saw evidence of multi-professional visits and appointments, for example GP, speech and language therapist, optician and dentist. Where people's needs were residential and not nursing any nursing which was required was provided through the community nursing service.

Is the service caring?

The service was caring because we saw how staff were observant to people's needs and responded appropriately. Throughout the inspection, we observed staff communicated appropriately with people, and we saw the relationships between staff and people in the home were positive. For example, touching a shoulder to provide comfort and sitting to speak at the same level with people unable to stand.

There were no negative comments about staff and comments included: 'Some lovely carers ' they are first class' and 'Staff are wonderful.'

Staff took time to consider how to improve people's lives. For example, people with high nursing needs were being enabled to sit at a new dining table, with new tableware for a better meal time experience. We saw how care workers took their time to help people eat at their own pace and encouraged their involvement.

Is the service responsive?

The service was responsive because people's likes and dislikes were taken into account. For example, how they wanted to spend their time, choice of food, providing fruit within reach and providing an exact number of pillows. This demonstrated that when staff were assisting people they would be able to know what kinds of things they liked and disliked in order to provide appropriate care and support.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives. For example, a staff member was personally taking a person to visit their family in the country.

Care files included personal information and identified the relevant people involved in their care. The care files were detailed for staff reference when providing care and support to ensure it was appropriate. Files included a history of people's pasts, which provided a timeline of significant events which had impacted on them at these times and how they impact on them now.

Is the service well-led?

The service was well-led because people's views and suggestions were taken into account to improve the service. For example, there was a comment book about the food in the dining room, resident and family meetings and a yearly survey of opinion, which was marked against the previous year's results.

Staff felt the service was well-led and their views were listened to. For example, they said equipment was provided when needed. There were comments about the need for improved communication and we saw from a staff meeting this had been discussed. The opinion of people using the service and staff was that more staff were required 'to provide company', 'the personal things like talking about family' and 'time to talk' which they recognised as important. The organisation was reviewing the staffing arrangements.

We saw that a range of audits were carried out. These were conducted on an on going basis to monitor the quality and safety of the service provided. Areas covered included care plans and medicines management. Where changes were needed these were followed up by the registered manager. For example, additional training in medication management.

Some people required nursing care whilst others were more independent.

We talked with ten people who live at Cadagan Court and in general people told us that they received good care. Some people made negative comments about the length of time it took to answer call bells and about the high use of agency staff. There were conflicting views about the availability of activities with one person telling us that there 'was nothing to do and nowhere to socialise', while another told us 'They are marvellous, we go on trips to the airport and other places.' On the day of our visit people from Exeter University were providing a 1950s themed event.

We found that people experienced support and treatment that generally met their needs, protected their rights and protected them from the risk of abuse. A person of some years in residence commented, 'I am fortunate to be here, the staff are extremely good to me and definitely help me'. Another said, 'I am so pleased to be allowed to look after my tablets myself'. However, we saw that appropriate records had not always been kept by staff about people's care and treatment.

Other people told us that they appreciated the way in which the staff cared for them. One person added 'We're not pushed about here'They're all very nice people.' Several people said they took part in at least some of the various activities offered, but told us staff did not have time to talk with them as much as they would have liked. Timely answering of call bells was also an issue.

The provider had systems to assess and monitor the quality of service that people received. Systems were also in place to identify and manage risks to the health, safety and welfare of people who used the service and others.